What are the responsibilities and job description for the Nurse RN position at Aditi Consulting?
Payrate: $45.00 - $47.00/hr.
Summary:
The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned to members based on an alpha split and then review clinical information provided by facilities to determine medical necessity when our members admit. You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.
Responsibilities:
- Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC and CMS evidenced based guidelines, policies and nationally recognized clinal criteria for BSC Medicare line of business.
- Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
- Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of members including levels of care, durable medical equipment, and post service needs to ensure quality and cost appropriate DC planning
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
- Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
- Refer to Case Management when there are acute inpatient needs affecting discharge
- Attend staff meetings, clinical rounds and weekly huddles
- Maintain quality and productivity metrics for all casework
- Buddy or support for new employees
- Maintaining HIPAA compliant workspace for telework environment
Required Skills:
- Strong Clinical Background with a minimum of 5 years of prior relevant experience doing direct inpatient care in the hospital setting.
- Strong communication and computer navigation skills
- Strong critical thinking skills
Preferred Skills:
- UM experience with knowledge of MCG Criteria
- ER and/or ICU experience
- Medicare experience
Pay Transparency: The typical base pay for this role across the U.S. is: $45.00 - $47.00/hr. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience and the benefits package you select. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, 10 paid days off, 401(k) plan participation, commuter benefits and life and disability insurance.
Consent to Communication and Use of AI Technology: By submitting your application for this position and providing your email address(es) and/or phone number(s), you consent to receive text (SMS), email, and/or voice communication whether automated (including auto telephone dialing systems or automatic text messaging systems), pre-recorded, AI-assisted, or individually initiated from Aditi Consulting, our agents, representatives, or affiliates at the phone number and/or email address you have provided. These communications may include information about potential opportunities and information. Message and data rates may apply. Message frequency may vary.
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Salary : $45 - $47